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Learn more about Dr. Hogan’s recent trip to the Democratic Republic of Congo! For photos, … Read More
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by Kathleen A. Hogan, MD
The holidays are a time when many people eat and drink a bit too much and then resolve to lose that weight in the new year. Unfortunately, once weight is gained, it is often difficult to lose. Many people notice that gaining weight seems to affect their joints, causing knee pain. Does excessive body weight cause knee arthritis or just make the symptoms worse?
Symptomatic knee arthritis affects approximately 13% of women and 10% of men over the age of 60 in the United States. There are many causes of knee arthritis including age, injury, mechanical mal-alignment, and genetic factors. Multiple studies have shown a relationship between body weight and the development of knee arthritis. For example, a person with a body mass index (BMI) of over 30 (obese) has an almost 7 times increases in the incidence of knee arthritis compared to someone with a BMI of less than 25 (normal weight). A BMI increase of 5 points is associated with an over 30% increase in the prevalence of knee arthritis.
How does this increased weight cause knee arthritis? Elevated body weight increases the mechanical stresses on the knee joint. Every 1 pound of weight gained increases the forces on the knee by a factor of 4. Decreased activity many lead to decreased muscle strength which also increases joint reactive forces. Gait analysis studies have shown that the compressive and sheer forces on the tibia-femoral joint are much higher in patients with elevated body mass compared to normal weight individuals. In a study of identical twins, every 1 kg weight gain (2.2 lbs) was found to increase the likelihood of X-ray findings of arthritis in the knee and hands by 9-13%. It is also thought that there may be metabolic and inflammatory factors in patients who are overweight which also contribute to cartilage damage, even in non weight bearing joints such as the hand. Inflammatory cytokines such as TNF alpha and interleukin -1 and adipokines such as leptin and adionectin are elevated in patients with obesity. The role of these factors in the development of arthritis is currently being studied.
Does losing weight help with knee pain even if you have arthritis? Yes, multiple studies show that weight loss does have beneficial effects, even in patients with x-ray findings of arthritis. Women in the Framingham Knee Osteoarthritis Study who lost weight (BMI decrease of 2 points) significantly decreased their probability of developing knee arthritis. Other studies have shown that when obese patients were able to lose 10% of their body weight, there was a significant improvement in knee pain, physical function, and decreased knee compressive forces with walking. MRIs can also show improvement in knee cartilage with weight loss. The American Academy of Orthopedic Surgeons (AAOS) recommends weight loss through diet and exercise for patients with knee arthritis and a BMI of > 25. Multiple studies have shown the benefit of low impact aerobic exercise and strengthening to improve the symptoms of knee arthritis.
Gaining weight can certainly increase the likelihood of developing joint pain and arthritis. If you find yourself putting on a few pounds over the holiday, make sure you stick to your New Years resolution to shed those pounds, as they tend to accumulate if not gotten rid of quickly! While knee arthritis can not always be prevented, low impact exercise, strength training, and maintaining a healthy body weight can help decrease your chance of needing joint replacement in the future.
by: Kathleen A. Hogan, MD
It is hard not to notice when a women walks down the street or through the hospital in 3 inch stiletto heels. It is estimated that over 40% of women wear high heals daily. Most of these shoes are not comfortable after several hours of wear and the potential negative effects of tight fitting shoes on the feet are well established. Wearing heels can also cause the muscles in the back of the leg to tighten, making it difficult for some women to place their heel on the ground when walking in flats.
But does wearing high heels do damage to other joints? Women have a higher rate of osteoarthritis of the knee compared to men. It is not well established if this increased incidence is a result of differences in hormone levels, obesity rates, or anatomy. Could wearing high heels increase the risk of arthritis?
Many women who have knee problems will stop wearing high heels because they hurt. Also, many women find as they get older they no longer wish to wear shoes that are not comfortable and that may increase their risk of falls. However, this does not prove that high heels cause arthritis.
There are only a few studies that have looked at the biomechanics of knee motion while wearing high heels. In one study, 14 women were asked to walk in sneakers, 1.5 inch heals, and 3 inch heals. As heel height increased, walking speed decreased. Knee flexion increased at heal strike and mid stance. Knee adduction also increased as heel height increased, indicating possibly more reactive forces placed on the knee joint. Other studies have shown increased knee torque and patellofemoral joint reactive forces when high heels are worn.
These studies do not mean that wearing high heels causes arthritis. However, certainly wearing heals will alter gait and may lead to knee pain. Other than wearing sneakers, what can be done to minimize the effects of this increased stress on the knee?
Balance is a crucial part of gait. Can you stand on one leg without loosing your balance? Can you do that in heels? When you walk, you spend a portion of your stride with one leg off the ground. If your balance is poor, you will put more stress on the muscles of your hip and knee as you struggle to compensate. Improving balance and strengthening gluteal muscles will take stress off the knees and hips as you walk in heels. Squats and lunges help to improve your dynamic stability.
Standing in heels changes the center of gravity, requiring more effort by the muscles of the low back to keep you standing straight. Core exercises to strengthen the abdominal and low back muscles are essential to maintaining good posture while wearing heels.
Stretching is also important Yixing Teapots. The calf and foot muscles tighten and contract to maintain that position. If these muscles are not routinely stretched and lengthened, they may become permanently contracted and stiff.
Although wearing high heels has been shown to place additional stresses on the feet and knees, there is no definitive proof that these added stresses result in arthritis. The added stress on the knees of being overweight is a much more important factor in the development of knee arthritis than shoe wear. Flexibility and strength are key to maintaining good posture while walking in heels. Limit the height of your heels to shoes you can balance in while standing on one leg. Find shoes that are more comfortable, with a wider toe box and thicker heel if necessary. And never let anyone talk you out of wearing shoes that you love.
by: Kathleen A. Hogan, MD
I am part of a group of female orthopedic surgeons (WOGO) who travel to third world countries to improve the lives of people by improving mobility through joint replacement. In July, we traveled to the Democratic Republic of Congo (DRC) as guests of the Dikembe Mutombo Foundation to perform knee replacement surgeries. This was an incredibly challenging trip and rewarding trip.
In four days of surgery, we replaced 42 knees. The last few days in DRC were bittersweet. We were exhausted from operating late almost every night. We were elated to have accomplished so much, but disappointed we did not get all the surgeries done. But time had run out. Another visiting surgeon had come to operate and we also didn’t want to leave the country the day after patients had just had surgery.
We had 2 days left. We packed cargo. We spent time with our patients. We traveled to an orphanage on the outskirts of Kinsasha. WOGO partners with Soles-4-Souls, a non profit organization which delivers shoes to people in third world countries. We visited with the children in the orphanage, and sat in the dirt to fit them with shoes. It was organized chaos with lots of smiling happy children. We also visited a maternity hospital. Many of us packed extra luggage full of baby onesies and blankets, and every new mother there went home went home with a care package of new baby clothes.
We did do a few “fun” activities while we were there. We spent an afternoon visiting the Lola ya Bonobo Sanctuary. Bonobos are members of the great ape family – as closely related to humans as are chimpanzees. Unlike chimps, they do not fight each other for food or dominance And the female bonobos are in charge. Bonobos live only in the Congo and are endangered. Their habitat has been devastated by civil war and monkeys are sold as gifts and eaten as food. This sanctuary was founded by a Congolese women who has dedicated her life to raising and protecting orphan bonobos.
We also saw the Congolese Symphony perform. Yes, in the midst of this poverty there is a symphony. It is the only symphony in Central Africa. Many of the musicians taught themselves to play on homemade instruments. They are unpaid and have other jobs during the day We saw them perform in an old school gymnasium and they were amazing.
If you read the stories of civil wars and child soldiers, and rape and corruption, you know that the people here have endured terrible tragedies. The poverty is unbelievable. Garbage litters city streets. Police officers and civil servants go without pay. Presidential elections are cancelled. Doctors work more than one job to pay the bills. I saw men with machine guns sitting on top of trucks. Yet the people we met were kind, friendly, and wonderful. They dress with a keen sense of fashion and color. People were genuinely happy we were there. The team of nurses and doctors at the hospital stayed late to help us out and often slept there. The police officers with machine guns who traveled with us cared about our safety and became part of our team too, even joining us in giving out shoes at the orphanage.
The last day at the hospital, we brought all the patients outside to take a group photo. All of the patients started clapping their hands and singing “God is so Good.” I cried. I think everyone did. It was an emotional, exhausting, amazing trip. The DRC is so much more than a failed state. I understand now why Dikembe Mutombo is so dedicated to helping the people from his homeland. His hospital does so many great things – vaccinations, cervical cancer screening, hearing aid distribution, cataract surgery, and now joint replacements. WOGO hopes to raise enough money to go back to DRC next year and continue helping the wonderful Congolese people. Learn more about our trip at Women Orthopaedist Global Outreach and the Dikembe Mutombo Foundation.
by: Kathleen A Hogan, MD
I am part of a group of female orthopedic surgeons (WOGO) who travel to third world countries to improve the lives of people by improving mobility through joint replacement. In July, we traveled to the Democratic Republic of Congo (DRC) as guests of the Dikembe Mutombo Foundation to perform knee replacement surgeries. This was an incredibly challenging trip and rewarding trip. This is our story.
Nothing went exactly as planned. Our cargo was delayed, resulting in one less surgical day. The sterilizer broke down. Many team members were hit hard by a GI illness. But we had rallied, working late into the evening and finding another nearby hospital to get our equipment autoclaved. We had performed 38 knee replacements. It was the last day for surgery. We knew that even under the best of circumstances there would probably be 6 patients for whom surgery would not happen. But we wanted to try.
We had a plan to get as many cases done as possible. Two surgeons ran the day-long educational conference for the local surgeons. Everyone else was in the operating room. But after the first cases were completed, the news was grim. The sterilizer was down again. Instruments were gathered up and sent to a nearby hospital to be autoclaved. But the slow down meant 6 patients would not have surgery.
We had met these patients in May and selected them for surgery. They had been in the hospital for the past 5 days awaiting surgery. They had gone through preoperative teaching and seen other patients recovering from surgery. Telling these 6 patients that their surgeries could not be performed was heartbreaking. Tears were shed – by the nurses, surgeons, and patients. But they all knew how hard we had tried to help them. These patients received steroid injections and braces prior to being discharged.
Later in the day we had to tell 2 more patients their surgery was also cancelled. These 2 patients were in the preoperative holding area when we realized that the equipment sterilized at the other hospital was not sterile and could not be used. It was such an emotional day. All of the surgeons believe that we have to go back to the Congo and finish the job we started. We all made a commitment to these patients that we would not forget them.
In the end, we were able to complete 42 knee replacements in 4 days of surgery. Our team worked long hours without complaints. The patients did really well after their surgeries. By the time we left, many had already been discharged home. They were walking with walkers or crutches and their pain was well controlled. Our physical therapists taught them exercises to do at home. We spent time with the surgeons who will be following up these patients teaching them about postoperative care for knee replacements. At the 2 week post op visit, all were doing well. We have established a great relationship with the surgeons at the hospital and we are working to help them get a wifi connection at the hospital to help facilitate email and video conferencing.
Not only did we help our patients, but we also helped to make the hospital a little bit better for those who follow in our footsteps. Because our group was coming, improvements had already been made in the operating rooms, including air conditioning. A new sterilizer is needed and will be ordered. After watching us perform a particularly difficult surgery, Rose Mutombo told me that we showed everyone in the operating room who was observing us the importance of getting the surgery done correctly, no matter how long it took. We had the opportunity to work alongside and teach the local surgeons, anesthesiologists, residents and nurses. The people of the Congo have suffered much with recent wars and political dictatorships and corruption. But they are beautiful, resilient people and there are so many good things happening in Congo!
by: Kathleen A. Hogan, MD
I am part of a group of female orthopedic surgeons (WOGO) who travel to third world countries to improve the lives of people by improving mobility through joint replacement. In July, we traveled to the Democratic Republic of Congo (DRC) as guests of the Dikembe Mutombo Foundation to perform knee replacement surgeries. This was an incredibly challenging trip. Here is Part 2 of our story.
As described in Part 1, our cargo had not yet cleared customs when we arrived in the country. We lost a day of surgery while the necessary signatures were obtained. Although we were at the hospital until midnight unpacking cargo, we were ready to start surgery the next day.
The buses left the hotel at 7:00am. We were tired but excited to start operating. The scrub techs quickly got started preparing the rooms and opening sterile drapes and instruments. The first patients were brought down to the preoperative area and our interpreters helped us answer patient questions. The anesthesiologists placed femoral nerve blocks and spinals.
By 9.30am, the first patients rolled into the operating rooms. We had 3 rooms, with 2 surgeons per room. The goal was to do 3 cases per room per day for a total of 9 patients. Most of the patients needed bilateral knee replacements. In addition to our team of an anesthesiologist, 2 surgeons, a surgical assist, and a circulating nurse, we were joined by surgeons and anesthesiologists from the hospital and orthopedic residents. We spent a lot of time teaching.
These were challenging surgeries as most of the knees were stiff and very deformed. The equipment we were using was not the small, minimally invasive state of the art instruments that we are used to in the United States. The surgical teams incorporated people from all over the country who last worked together 2 years ago on our last mission trip. The surgeries took a bit longer than usual because of these factors, but they all went really well.
We were focused on getting our cases done because we had already lost one day of surgery and the patients we had selected on the pre-trip had been admitted to the hospital in preparation for their surgeries. For that reason, I started my last case that first day at 9.30pm. It was another long day, with the early team not getting back to the hotel until after 10:00pm and the late team staying at the hospital past midnight. We were all exhausted but happy the cases had gone so well. Fourteen knee replacements were done! We were proud to have done the first knee replacements in Kinshasa, DRC.
The problems with the sterilizer started the next day. Because of issues with electricity and water pressure, not all of the equipment was sterile. Ruth Kanyere, the equipment engineer for the hospital was so helpful in trying to get the machine to work. The delays meant another long day, but by the end we had accomplished our goal of 14 more joints.
The third operating day was when everything started to fall apart. The sterilizer broke down again. We ended up sending some of our equipment to another hospital to be sterilized. We were able to do some cases. One of the surgeons was sick and had to return to the hotel. Other team members were hit by gastro-intestinal illnesses and were getting IV fluids. We were all exhausted.
For the first time we were not able to do all the cases scheduled for the day. Thirty-eight knee replacements had been completed. We started trying to figure out how we would be able to get all of the cases done. Even in the best case scenario, if the autoclave worked perfectly that night and the next day, it would be nearly impossible to do all the cases we had promised to do. We had only one more day left to operate as the OR was booked for another foreign surgeon for the remainder of the week. We started the difficult process of trying to decide which cases we could do. But we would wait until tomorrow to make the final decisions.
Read all the articles about this trip here.